Provider First Line Business Practice Location Address: 
405 E HARTSON AVE STE 4
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPOKANE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
99202-1329
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-624-2545
    Provider Business Practice Location Address Fax Number: 
509-624-1438
    Provider Enumeration Date: 
01/13/2015