Provider First Line Business Practice Location Address:
119 S 2ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-1307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-833-8894
Provider Business Practice Location Address Fax Number:
509-795-5472
Provider Enumeration Date:
06/26/2012