Provider First Line Business Practice Location Address:
501 LEWIS AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOLD BAR
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-793-1335
Provider Business Practice Location Address Fax Number:
360-793-8998
Provider Enumeration Date:
10/20/2006