Provider First Line Business Practice Location Address:
1003 WALLACE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANDVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98930-8805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-203-1088
Provider Business Practice Location Address Fax Number:
509-203-1077
Provider Enumeration Date:
02/02/2006