Provider First Line Business Practice Location Address: 
6517 N STEVENS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99208-4006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-350-3297
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/01/2023