Provider First Line Business Practice Location Address:
902-A SIXTH STREET
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-962-5326
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2014