Provider First Line Business Practice Location Address:
318 E MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOAP LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-797-3156
Provider Business Practice Location Address Fax Number:
509-246-1660
Provider Enumeration Date:
12/14/2009