Provider First Line Business Practice Location Address:
115 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-1321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-594-6386
Provider Business Practice Location Address Fax Number:
866-265-8885
Provider Enumeration Date:
12/26/2006