Provider First Line Business Practice Location Address:
1552 W GOODLANDER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-8760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-525-6650
Provider Business Practice Location Address Fax Number:
509-737-1494
Provider Enumeration Date:
01/12/2010