Provider First Line Business Practice Location Address: 
12B N UNIVERSITY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE VALLEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99206-5205
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-891-5900
    Provider Business Practice Location Address Fax Number: 
509-232-6646
    Provider Enumeration Date: 
01/09/2012