Provider First Line Business Practice Location Address:
105 FIR ST.
Provider Second Line Business Practice Location Address:
#327 SAC ANNEX BLDG.
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-2663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-246-3638
Provider Business Practice Location Address Fax Number:
360-844-5184
Provider Enumeration Date:
01/22/2024