Provider First Line Business Practice Location Address:
312 S BALSAM ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-1796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-766-1283
Provider Business Practice Location Address Fax Number:
509-766-0309
Provider Enumeration Date:
12/05/2007