Provider First Line Business Practice Location Address:
301 W POPLAR ST
Provider Second Line Business Practice Location Address:
SUITE 50
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-522-5765
Provider Business Practice Location Address Fax Number:
509-522-5516
Provider Enumeration Date:
09/19/2005