Provider First Line Business Practice Location Address:
21525 STATE ROUTE 410 E
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-826-8520
Provider Business Practice Location Address Fax Number:
253-826-8522
Provider Enumeration Date:
03/18/2007