Provider First Line Business Practice Location Address:
57953 FOOTHILL RD
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:
97850-5212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-539-2574
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2026