Provider First Line Business Practice Location Address:
110 STEVENS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COULEE DAM
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99116-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-633-2143
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/06/2006