Provider First Line Business Practice Location Address:
821 E BROADWAY AVE STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-350-4785
Provider Business Practice Location Address Fax Number:
509-380-9591
Provider Enumeration Date:
06/15/2012