Provider First Line Business Practice Location Address:
23801 E APPLEWAY AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-9687
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-660-4053
Provider Business Practice Location Address Fax Number:
509-279-2309
Provider Enumeration Date:
11/16/2009