Provider First Line Business Practice Location Address: 
806 W 16TH AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99203-2177
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
707-972-2736
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/03/2021