Provider First Line Business Practice Location Address:
109 NE BIRCH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99324-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-272-1673
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/17/2026