Provider First Line Business Practice Location Address:
1101 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:
98944-2264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-839-5656
Provider Business Practice Location Address Fax Number:
509-839-5682
Provider Enumeration Date:
10/18/2018