Provider First Line Business Practice Location Address:
1242 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99403-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-758-2523
Provider Business Practice Location Address Fax Number:
509-295-2952
Provider Enumeration Date:
11/09/2007