Provider First Line Business Practice Location Address:
228 W MAIN ST
Provider Second Line Business Practice Location Address:
MSCH-14
Provider Business Practice Location Address City Name:
GOLDENDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98620-9597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-493-1558
Provider Business Practice Location Address Fax Number:
509-493-4025
Provider Enumeration Date:
12/04/2006