Provider First Line Business Practice Location Address:
1423 E 29TH ST
Provider Second Line Business Practice Location Address:
SUITE 317
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98404-4008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-372-6618
Provider Business Practice Location Address Fax Number:
888-575-7414
Provider Enumeration Date:
10/27/2009