Provider First Line Business Practice Location Address:
901 S 12TH 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:
97850-3235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-299-4399
Provider Business Practice Location Address Fax Number:
541-507-0911
Provider Enumeration Date:
01/23/2015