Provider First Line Business Practice Location Address:
701 4TH 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:
97850-2003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-520-6906
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2026