Provider First Line Business Practice Location Address:
2400 UNIVERSITY LN APT 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHENEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99004-2055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-703-1209
Provider Business Practice Location Address Fax Number:
509-327-7816
Provider Enumeration Date:
12/04/2008