Provider First Line Business Practice Location Address:
4418 64TH AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-5628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-346-9923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2026