Provider First Line Business Practice Location Address:
215 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-1717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-771-9342
Provider Business Practice Location Address Fax Number:
509-765-0204
Provider Enumeration Date:
01/11/2010