Provider First Line Business Practice Location Address:
1902 4TH ST STE 3
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:
97850-2558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-9843
Provider Business Practice Location Address Fax Number:
541-963-8746
Provider Enumeration Date:
09/27/2006