Provider First Line Business Practice Location Address:
21200 E COUNTRY VISTA DR APT I202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-7681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-868-4747
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2007