Provider First Line Business Practice Location Address:
4001 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOON LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99148-9761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-233-2212
Provider Business Practice Location Address Fax Number:
509-233-2537
Provider Enumeration Date:
07/09/2006