Provider First Line Business Practice Location Address:
127 2ND AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOAP LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98851-0958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-246-0540
Provider Business Practice Location Address Fax Number:
509-246-0358
Provider Enumeration Date:
10/01/2007