Provider First Line Business Practice Location Address: 
6212 N CHASE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEWMAN LAKE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99025-8657
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-226-0529
    Provider Business Practice Location Address Fax Number: 
509-621-0322
    Provider Enumeration Date: 
12/30/2014