Provider First Line Business Practice Location Address:
1427 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE B-1
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-3649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-802-0244
Provider Business Practice Location Address Fax Number:
866-584-9044
Provider Enumeration Date:
11/30/2006