Provider First Line Business Practice Location Address:
830 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-5932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-766-9966
Provider Business Practice Location Address Fax Number:
509-766-0083
Provider Enumeration Date:
03/29/2007