Provider First Line Business Practice Location Address: 
506 S JACKSON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RITZVILLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99169-2106
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-659-1600
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/29/2014