Provider First Line Business Practice Location Address:
2008 3RD ST STE B
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:
97850-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-9632
Provider Business Practice Location Address Fax Number:
541-963-6346
Provider Enumeration Date:
12/21/2006