Provider First Line Business Practice Location Address:
3994 COLVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOON LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99148-9789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-233-8412
Provider Business Practice Location Address Fax Number:
509-233-2864
Provider Enumeration Date:
04/17/2006