Provider First Line Business Practice Location Address:
3102 ISLAND AVE
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:
97850-9498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-8494
Provider Business Practice Location Address Fax Number:
541-962-7291
Provider Enumeration Date:
12/20/2006