Provider First Line Business Practice Location Address:
19950 S PRAIRIE RD E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-7901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-862-1555
Provider Business Practice Location Address Fax Number:
253-862-1557
Provider Enumeration Date:
03/18/2009