Provider First Line Business Practice Location Address:
210 E FIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-707-9430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2021