Provider First Line Business Practice Location Address:
11818 SE MILL PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 311C
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-571-3981
Provider Business Practice Location Address Fax Number:
503-578-2454
Provider Enumeration Date:
09/07/2006