Provider First Line Business Practice Location Address:
8004 SO. 5TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-459-1253
Provider Business Practice Location Address Fax Number:
360-887-5184
Provider Enumeration Date:
02/22/2007