Provider First Line Business Practice Location Address:
11015 NE FOURTH PLAIN RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98662-6314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-892-0451
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/09/2008