Provider First Line Business Practice Location Address: 
1305 N SUNDERLAND RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE VALLEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99206-4087
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
406-868-8992
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/02/2009