Provider First Line Business Practice Location Address:
1110 N TARA LEE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-8941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-822-0911
Provider Business Practice Location Address Fax Number:
800-539-7611
Provider Enumeration Date:
03/02/2026