Provider First Line Business Practice Location Address:
917 NE 192ND AVE
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:
98684-7537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-896-6037
Provider Business Practice Location Address Fax Number:
360-944-0144
Provider Enumeration Date:
10/19/2006