Provider First Line Business Practice Location Address:
109 E WYNOT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NINE MILE FALLS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99026-9313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-822-1074
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2025