Provider First Line Business Practice Location Address: 
2411 S CHERRY CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE VALLEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99216-0340
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-473-5494
    Provider Business Practice Location Address Fax Number: 
509-473-5998
    Provider Enumeration Date: 
04/20/2006