Provider First Line Business Practice Location Address:
1119 HIGHLAND AVENUE
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-1119
Provider Business Practice Location Address Fax Number:
509-758-1140
Provider Enumeration Date:
03/22/2007