Provider First Line Business Practice Location Address:
720 S CLARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REPUBLIC
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-775-0233
Provider Business Practice Location Address Fax Number:
509-775-8029
Provider Enumeration Date:
02/28/2007