Provider First Line Business Practice Location Address:
1355 E HEMLOCK ST
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:
99344-1576
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-488-5216
Provider Business Practice Location Address Fax Number:
509-488-9496
Provider Enumeration Date:
11/30/2006