Provider First Line Business Practice Location Address:
120 E BIRCH ST
Provider Second Line Business Practice Location Address:
SUITE 11
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-3054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-7800
Provider Business Practice Location Address Fax Number:
509-529-0835
Provider Enumeration Date:
11/18/2005