Provider First Line Business Practice Location Address: 
1065 SAINT JOHN ST
    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: 
99362-4173
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-300-7605
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/24/2022