Provider First Line Business Practice Location Address:
7792 40TH ST W APT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-3148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-576-2943
Provider Business Practice Location Address Fax Number:
253-565-0304
Provider Enumeration Date:
01/25/2007