Provider First Line Business Practice Location Address: 
3321 W KENNEWICK AVE STE 150
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KENNEWICK
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99336-2968
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-735-6446
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/18/2025