Provider First Line Business Practice Location Address: 
5219 W CLEARWATER AVE STE 13
    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: 
99336-1980
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-593-8777
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/16/2021