Provider First Line Business Practice Location Address:
115 W COURT ST
Provider Second Line Business Practice Location Address:
ROOM# 103
Provider Business Practice Location Address City Name:
GOLDENDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98620-8905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-773-4565
Provider Business Practice Location Address Fax Number:
509-773-5991
Provider Enumeration Date:
08/17/2007