Provider First Line Business Practice Location Address:
200 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-1718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-765-1217
Provider Business Practice Location Address Fax Number:
509-765-4410
Provider Enumeration Date:
09/28/2011