Provider First Line Business Practice Location Address:
MPO 12 R BUTLER LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKAMANIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-427-8239
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/30/2006