Provider First Line Business Practice Location Address:
1860 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-346-6005
Provider Business Practice Location Address Fax Number:
509-488-5232
Provider Enumeration Date:
05/19/2023