Provider First Line Business Practice Location Address:
10510 GRAVELLY LAKE DR SW
Provider Second Line Business Practice Location Address:
LAKEWOOD CLINIC
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-5036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-589-7030
Provider Business Practice Location Address Fax Number:
253-589-7033
Provider Enumeration Date:
10/19/2006