Provider First Line Business Practice Location Address:
26 WEST H STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-276-7522
Provider Business Practice Location Address Fax Number:
509-276-7522
Provider Enumeration Date:
06/23/2006