Provider First Line Business Practice Location Address:
212 W 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAPATO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98951-1308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-877-4552
Provider Business Practice Location Address Fax Number:
509-877-6077
Provider Enumeration Date:
10/12/2006