Provider First Line Business Practice Location Address: 
2611 E MORAN VISTA LN STE B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99223-2101
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-448-5970
    Provider Business Practice Location Address Fax Number: 
855-640-5074
    Provider Enumeration Date: 
08/10/2007