Provider First Line Business Practice Location Address:
1911 S ESPANOLA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-9627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-991-7314
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/10/2020