Provider First Line Business Practice Location Address:
1002 S 3RD STREET
Provider Second Line Business Practice Location Address:
STE 2
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-382-2181
Provider Business Practice Location Address Fax Number:
509-382-2942
Provider Enumeration Date:
10/20/2006