Provider First Line Business Practice Location Address:
12618 W SUNNYVALE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NINE MILE FALLS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99026-9371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-987-0542
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2026