Provider First Line Business Practice Location Address:
23009 W SPRAGUE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REARDAN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99029-9667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-714-1006
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/05/2026