Provider First Line Business Practice Location Address:
2401 ROAD 1.4 NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-9127
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-766-7966
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/15/2019