Provider First Line Business Practice Location Address: 
21200 E COUNTRY VISTA DR
    Provider Second Line Business Practice Location Address: 
D101
    Provider Business Practice Location Address City Name: 
LIBERTY LAKE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99019-7636
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
623-521-8653
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/29/2011