Provider First Line Business Practice Location Address:
226 MAIN AVE EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOAP LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98851-0045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-398-6437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2016