Provider First Line Business Practice Location Address:
19652 ROAD A.5 NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOAP LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98851-9613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-431-8059
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2017