Provider First Line Business Practice Location Address:
1612 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-2516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-809-1669
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2023