Provider First Line Business Practice Location Address:
744 5TH ST
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-295-6163
Provider Business Practice Location Address Fax Number:
509-295-6160
Provider Enumeration Date:
07/31/2012