Provider First Line Business Practice Location Address:
19 E BIRCH ST STE 103
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:
99362-3084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-200-7290
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2012