Provider First Line Business Practice Location Address:
7521 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-475-0118
Provider Business Practice Location Address Fax Number:
253-475-0174
Provider Enumeration Date:
11/02/2009