Provider First Line Business Practice Location Address:
4268 ROAD K.1 NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-8492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-619-2512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/16/2012