Provider First Line Business Practice Location Address:
980 COLLINS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-8914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-865-1694
Provider Business Practice Location Address Fax Number:
509-865-1530
Provider Enumeration Date:
10/28/2025