Provider First Line Business Practice Location Address:
1016 TACOMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYSIDE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98944-2263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-837-1708
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/24/2006