Provider First Line Business Practice Location Address:
10454 FOX RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98826-9515
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-548-4780
Provider Business Practice Location Address Fax Number:
509-888-3956
Provider Enumeration Date:
03/23/2012