Provider First Line Business Practice Location Address:
315 N 14TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1254
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-331-2664
Provider Business Practice Location Address Fax Number:
509-331-3857
Provider Enumeration Date:
05/24/2007