Provider First Line Business Practice Location Address: 
1417 LAKESIDE CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
YAKIMA
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98902-7354
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-494-0121
    Provider Business Practice Location Address Fax Number: 
509-494-0171
    Provider Enumeration Date: 
07/19/2016