Provider First Line Business Practice Location Address:
21950 E COUNTRY VISTA DR
Provider Second Line Business Practice Location Address:
SUITE 600
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-6005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-590-1343
Provider Business Practice Location Address Fax Number:
866-774-8216
Provider Enumeration Date:
10/27/2010