Provider First Line Business Practice Location Address:
143 N KAUFFMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-239-3362
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2016