Provider First Line Business Practice Location Address:
110 S BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OTHELLO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99344-1346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-989-0875
Provider Business Practice Location Address Fax Number:
509-488-7224
Provider Enumeration Date:
04/02/2007