Provider First Line Business Practice Location Address:
22106 E COUNTRY VISTA DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
LIBERTY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99019-6017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-893-1119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2014