Provider First Line Business Practice Location Address:
139 PRAIRIE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELSO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98626-5300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-431-9113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2026