Provider First Line Business Practice Location Address:
1012 SOUTH THIRD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-382-2531
Provider Business Practice Location Address Fax Number:
509-382-3205
Provider Enumeration Date:
07/14/2005