Provider First Line Business Practice Location Address:
1298 SE 12TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-529-1469
Provider Business Practice Location Address Fax Number:
509-525-0387
Provider Enumeration Date:
07/27/2007