Provider First Line Business Practice Location Address:
506 RIVERSIDE DRIVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
OMAK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98841
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-826-7165
Provider Business Practice Location Address Fax Number:
509-826-1179
Provider Enumeration Date:
03/28/2007