Provider First Line Business Practice Location Address:
2709 W BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-2904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-765-9332
Provider Business Practice Location Address Fax Number:
509-765-4761
Provider Enumeration Date:
09/14/2009