Provider First Line Business Practice Location Address:
1612 PENNY LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WALLA WALLA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99362-4477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-2130
Provider Business Practice Location Address Fax Number:
509-527-0403
Provider Enumeration Date:
08/07/2012