Provider First Line Business Practice Location Address: 
303 EAST JOHNSON
    Provider Second Line Business Practice Location Address: 
LAKE CHELAN SCHOOL DISTRICT
    Provider Business Practice Location Address City Name: 
CHELAN
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98816
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-682-7744
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/30/2014