Provider First Line Business Practice Location Address:
1107 E SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-331-4017
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/05/2022