Provider First Line Business Practice Location Address:
1119 LAWRENCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PT TOWNSEND
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98368-6525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-385-5121
Provider Business Practice Location Address Fax Number:
360-379-9534
Provider Enumeration Date:
09/13/2005