Provider First Line Business Practice Location Address:
10419 12TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-1812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-251-3185
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2005