Provider First Line Business Practice Location Address:
23610 E BROADWAY 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:
99019-9641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-292-2258
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2010