Provider First Line Business Practice Location Address:
306 MIDWAY AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND COULEE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99133-0180
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-633-1150
Provider Business Practice Location Address Fax Number:
509-633-1370
Provider Enumeration Date:
07/29/2005