Provider First Line Business Practice Location Address:
1404 4TH 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:
97850-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-612-7555
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2016