Provider First Line Business Practice Location Address:
206 DEPOT ST
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:
97850-2619
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-5741
Provider Business Practice Location Address Fax Number:
541-963-6332
Provider Enumeration Date:
06/14/2006