Provider First Line Business Practice Location Address:
390442 SR 20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUSICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-442-2311
Provider Business Practice Location Address Fax Number:
509-442-2333
Provider Enumeration Date:
06/30/2005