Provider First Line Business Practice Location Address:
904 NW 148TH 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:
98685-1039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-952-1068
Provider Business Practice Location Address Fax Number:
360-571-2349
Provider Enumeration Date:
09/28/2026