Provider First Line Business Practice Location Address: 
316 W BOONE AVE STE 656
    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: 
99201-2346
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-928-1651
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/23/2022