Provider First Line Business Practice Location Address:
304 S 1ST ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98942-2005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-697-5330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/06/2013