Provider First Line Business Practice Location Address:
4109 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-884-3385
Provider Business Practice Location Address Fax Number:
253-884-3385
Provider Enumeration Date:
12/27/2006