Provider First Line Business Practice Location Address:
120 NE 117TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-448-8233
Provider Business Practice Location Address Fax Number:
360-449-3197
Provider Enumeration Date:
10/19/2007