Provider First Line Business Practice Location Address:
6808 NE FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-0217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-750-7220
Provider Business Practice Location Address Fax Number:
360-750-4488
Provider Enumeration Date:
11/13/2006