Provider First Line Business Practice Location Address: 
2201 N 30TH ST C
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TACOMA
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98403
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-254-5737
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/25/2018