Provider First Line Business Practice Location Address:
1215 W LEWIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASCO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99301-5472
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-543-6703
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2012