Provider First Line Business Practice Location Address:
520 11TH ST NE
Provider Second Line Business Practice Location Address:
APT. 26
Provider Business Practice Location Address City Name:
EAST WENATCHEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98802-4285
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-257-6889
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2009