Provider First Line Business Practice Location Address:
733 5TH ST
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2671
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-7258
Provider Business Practice Location Address Fax Number:
509-758-7258
Provider Enumeration Date:
08/18/2006