Provider First Line Business Practice Location Address: 
25784 HOEHN RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SEDRO WOOLLEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98284-8371
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-224-3138
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/31/2016