Provider First Line Business Practice Location Address:
1133 N GRAPE DR
Provider Second Line Business Practice Location Address:
B204
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-4052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-750-1549
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2009