Provider First Line Business Practice Location Address:
9612 NE 101ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98662-3355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
564-266-3598
Provider Business Practice Location Address Fax Number:
760-428-1941
Provider Enumeration Date:
10/21/2026