Provider First Line Business Practice Location Address:
925 NE 136TH AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684-0896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-694-5559
Provider Business Practice Location Address Fax Number:
360-891-0000
Provider Enumeration Date:
10/27/2006