Provider First Line Business Practice Location Address:
708 PENN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKES
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-764-5206
Provider Business Practice Location Address Fax Number:
509-764-5207
Provider Enumeration Date:
01/09/2007