Provider First Line Business Practice Location Address:
23324 E INLET DR
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:
99019-9786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-255-9635
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2012