Provider First Line Business Practice Location Address:
821 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-765-1602
Provider Business Practice Location Address Fax Number:
509-766-9778
Provider Enumeration Date:
06/23/2005