Provider First Line Business Practice Location Address:
1304 DALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTON CITY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99320-8831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-588-3212
Provider Business Practice Location Address Fax Number:
509-588-4343
Provider Enumeration Date:
05/17/2007