Provider First Line Business Practice Location Address: 
115 W KENNEWICK AVE
    Provider Second Line Business Practice Location Address: 
SUITE 201
    Provider Business Practice Location Address City Name: 
KENNEWICK
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99336-3831
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-586-9700
    Provider Business Practice Location Address Fax Number: 
509-735-5397
    Provider Enumeration Date: 
02/16/2011