Provider First Line Business Practice Location Address:
17963 ROAD B NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EPHRATA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98823-9479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-760-6620
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2026