Provider First Line Business Practice Location Address:
100 W 11TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98660-3352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-693-2112
Provider Business Practice Location Address Fax Number:
360-735-9058
Provider Enumeration Date:
09/29/2009