Provider First Line Business Practice Location Address:
116 S 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-855-6921
Provider Business Practice Location Address Fax Number:
509-488-0818
Provider Enumeration Date:
07/10/2009