Provider First Line Business Practice Location Address:
105 W ORCHARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-1329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-697-6177
Provider Business Practice Location Address Fax Number:
509-697-6659
Provider Enumeration Date:
03/14/2007