Provider First Line Business Practice Location Address:
21220 SR 410 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-8458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-447-4770
Provider Business Practice Location Address Fax Number:
253-447-4771
Provider Enumeration Date:
09/14/2009