Provider First Line Business Practice Location Address: 
6516 WEST TERRACE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHENEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99004-8574
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-216-5151
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/05/2014