Provider First Line Business Practice Location Address:
1612 PENNY LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-4474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-2130
Provider Business Practice Location Address Fax Number:
509-526-3640
Provider Enumeration Date:
07/11/2006