Provider First Line Business Practice Location Address: 
1724 W CARLISLE AVE
    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: 
99205-3616
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-536-1838
    Provider Business Practice Location Address Fax Number: 
509-536-7463
    Provider Enumeration Date: 
08/24/2006