Provider First Line Business Practice Location Address:
605 S COOLIDGE ST
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:
98837-1893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-765-0674
Provider Business Practice Location Address Fax Number:
509-766-8993
Provider Enumeration Date:
10/15/2009