Provider First Line Business Practice Location Address:
2202 OLD HWY 99 SOUTH ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-542-8810
Provider Business Practice Location Address Fax Number:
206-766-6993
Provider Enumeration Date:
01/26/2007