Provider First Line Business Practice Location Address:
112 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANGER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-383-6172
Provider Business Practice Location Address Fax Number:
509-383-6173
Provider Enumeration Date:
07/20/2016