Provider First Line Business Practice Location Address:
9438 BASELINE.1 RD NE
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:
98837-9027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-470-0502
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2025