Provider First Line Business Practice Location Address:
209 N AHTANUM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAPATO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98951-1125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-877-3175
Provider Business Practice Location Address Fax Number:
509-877-6135
Provider Enumeration Date:
09/13/2005