Provider First Line Business Practice Location Address:
1818 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SUMNER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98390-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-988-0967
Provider Business Practice Location Address Fax Number:
253-848-5224
Provider Enumeration Date:
12/21/2007