Provider First Line Business Practice Location Address:
20 EAST J STREET SUITE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-276-8809
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2007