Provider First Line Business Practice Location Address:
1010 W FIR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-565-4585
Provider Business Practice Location Address Fax Number:
509-565-4649
Provider Enumeration Date:
09/01/2016