Provider First Line Business Practice Location Address:
112 W. MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLDENDALE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-773-5801
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2007