Provider First Line Business Practice Location Address:
12620 NE 51ST 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:
98682-2272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-501-9272
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/17/2026