Provider First Line Business Practice Location Address:
215 N COLVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEER PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99006-5015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-276-9016
Provider Business Practice Location Address Fax Number:
509-276-8890
Provider Enumeration Date:
02/27/2012