Provider First Line Business Practice Location Address:
1038 W IVY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-766-7960
Provider Business Practice Location Address Fax Number:
509-766-6595
Provider Enumeration Date:
11/07/2007