Provider First Line Business Practice Location Address:
109 S MITCHELL CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-9431
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-255-1222
Provider Business Practice Location Address Fax Number:
509-255-1133
Provider Enumeration Date:
05/30/2007