Provider First Line Business Practice Location Address:
204 12TH AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EPHRATA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98823-2197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-754-6199
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2018