Provider First Line Business Practice Location Address:
12992 ROAD 12 NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-9394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-941-1376
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2012