Provider First Line Business Practice Location Address:
1601 E FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
BLDG 17, STE B222
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:
360-397-8484
Provider Business Practice Location Address Fax Number:
360-397-8494
Provider Enumeration Date:
07/15/2009