Provider First Line Business Practice Location Address:
4409 S ESPANOLA RD
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:
99022-8638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-954-5616
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2016