Provider First Line Business Practice Location Address:
17609 N LIDGERWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLBERT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99005-9201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-302-9866
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/22/2026