Provider First Line Business Practice Location Address:
401 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006-8238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-462-6572
Provider Business Practice Location Address Fax Number:
509-276-2490
Provider Enumeration Date:
10/27/2005