Provider First Line Business Practice Location Address:
445 E CEDAR BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-331-6308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/03/2015