Provider First Line Business Practice Location Address:
21808 E INDIANA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-425-0088
Provider Business Practice Location Address Fax Number:
509-416-2030
Provider Enumeration Date:
03/31/2026