Provider First Line Business Practice Location Address:
105 1/2 W LOCUST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-745-8095
Provider Business Practice Location Address Fax Number:
509-745-9096
Provider Enumeration Date:
07/30/2006