Provider First Line Business Practice Location Address:
12422 E MANSFIELD AVE APT 90
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99216-1167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-990-6104
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2007