Provider First Line Business Practice Location Address: 
56 N COLLEGE AVE #2A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLLEGE PLACE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99324
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-240-6068
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/24/2018