Provider First Line Business Practice Location Address:
NORTH 6 CLARK ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99166-0497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-775-3351
Provider Business Practice Location Address Fax Number:
509-775-3978
Provider Enumeration Date:
11/08/2006