Provider First Line Business Practice Location Address:
221 CEDAR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MABTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-830-9901
Provider Business Practice Location Address Fax Number:
509-894-4954
Provider Enumeration Date:
03/26/2009