Provider First Line Business Practice Location Address:
916 S JOSEPHINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSALIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99170-9550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-523-3061
Provider Business Practice Location Address Fax Number:
509-523-3861
Provider Enumeration Date:
10/18/2006