Provider First Line Business Practice Location Address:
507 BURKE AVE UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98826-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-275-3119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2016