Provider First Line Business Practice Location Address:
360 SW 12 ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-540-9122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007