Provider First Line Business Practice Location Address: 
110 E 17TH AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELLENSBURG
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98926-2518
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-929-1357
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/20/2011