Provider First Line Business Practice Location Address:
1808 4TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-2548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-3118
Provider Business Practice Location Address Fax Number:
541-963-2821
Provider Enumeration Date:
06/19/2006