Provider First Line Business Practice Location Address:
318 S 1ST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-697-4123
Provider Business Practice Location Address Fax Number:
509-697-4423
Provider Enumeration Date:
07/13/2005