Provider First Line Business Practice Location Address:
1268 BRIDGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-9524
Provider Business Practice Location Address Fax Number:
509-758-8258
Provider Enumeration Date:
07/12/2011