Provider First Line Business Practice Location Address:
524 S HALLETT
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:
99022-0128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-565-3405
Provider Business Practice Location Address Fax Number:
509-565-3400
Provider Enumeration Date:
05/28/2013