Provider First Line Business Practice Location Address:
541 S EVERGREEN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-8901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-368-1867
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2012