Provider First Line Business Practice Location Address:
4103 BRIDGEPORT WAY W STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-460-1824
Provider Business Practice Location Address Fax Number:
253-460-1920
Provider Enumeration Date:
02/06/2007