Provider First Line Business Practice Location Address:
1221 SE ELLSWORTH RD
Provider Second Line Business Practice Location Address:
APT Q183
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-6299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-448-5060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2008