Provider First Line Business Practice Location Address: 
664 6TH ST
    Provider Second Line Business Practice Location Address: 
STE B
    Provider Business Practice Location Address City Name: 
CLARKSTON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99403-2007
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-316-9144
    Provider Business Practice Location Address Fax Number: 
801-396-7066
    Provider Enumeration Date: 
09/09/2021