Provider First Line Business Practice Location Address:
511 S ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOPPENISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98948-1651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-865-5121
Provider Business Practice Location Address Fax Number:
509-984-3793
Provider Enumeration Date:
11/05/2012