Provider First Line Business Practice Location Address:
485 SE E STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-636-2721
Provider Business Practice Location Address Fax Number:
509-636-2910
Provider Enumeration Date:
09/05/2006