Provider First Line Business Practice Location Address:
1502 N PINE ST
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-3543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-8585
Provider Business Practice Location Address Fax Number:
541-963-6633
Provider Enumeration Date:
02/17/2015