Provider First Line Business Practice Location Address:
194 N. PORTLAND ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99166-0978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-775-3169
Provider Business Practice Location Address Fax Number:
509-775-2272
Provider Enumeration Date:
04/28/2010