Provider First Line Business Practice Location Address: 
7995 ADAMS RD S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROYAL CITY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99357-9555
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-760-9616
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/17/2024