Provider First Line Business Practice Location Address:
617 E COLLINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDENDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98620-9213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-773-5545
Provider Business Practice Location Address Fax Number:
509-773-6718
Provider Enumeration Date:
07/24/2006