Provider First Line Business Practice Location Address:
428 NORTH MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006-0190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-464-5521
Provider Business Practice Location Address Fax Number:
509-464-5572
Provider Enumeration Date:
10/04/2006