Provider First Line Business Practice Location Address:
8012 W WILD ROSE RD
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:
99006-9753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-220-8914
Provider Business Practice Location Address Fax Number:
509-220-8914
Provider Enumeration Date:
04/30/2026