Provider First Line Business Practice Location Address:
37 MAPLE ST 144
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:
509-361-4643
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/13/2026