Provider First Line Business Practice Location Address:
23410 E MISSION AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-7515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-999-4780
Provider Business Practice Location Address Fax Number:
509-924-8242
Provider Enumeration Date:
12/24/2008