Provider First Line Business Practice Location Address:
12014 SE MILL PLAIN BLVD STE 120
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:
98684-4044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-297-1405
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2026