Provider First Line Business Practice Location Address:
1294 CHESTNUT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-769-6349
Provider Business Practice Location Address Fax Number:
509-758-8139
Provider Enumeration Date:
08/31/2006