Provider First Line Business Practice Location Address:
12730 ROAD 1.5 SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSES LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98837-9467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-765-8041
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2012