Provider First Line Business Practice Location Address:
550 WINE COUNTRY RD TRLR 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PROSSER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99350-7598
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-201-7372
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2026