Provider First Line Business Practice Location Address:
317 N BROAD ST
Provider Second Line Business Practice Location Address:
BOX 128
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-8763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-565-3145
Provider Business Practice Location Address Fax Number:
509-565-3149
Provider Enumeration Date:
05/22/2013