Provider First Line Business Practice Location Address: 
7888 BERTRAM WAY 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: 
98837-9883
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-760-2827
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/17/2006