Provider First Line Business Practice Location Address:
147 N. CLARK AVE #12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-775-2958
Provider Business Practice Location Address Fax Number:
509-775-2937
Provider Enumeration Date:
10/13/2006