Provider First Line Business Practice Location Address: 
7817 PACIFIC AVE
    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: 
98408-7036
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-272-6061
    Provider Business Practice Location Address Fax Number: 
253-472-6195
    Provider Enumeration Date: 
04/11/2013