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:
12/04/2006