Provider First Line Business Practice Location Address:
1603 E FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-3753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-4061
Provider Business Practice Location Address Fax Number:
360-737-1443
Provider Enumeration Date:
06/26/2006