Provider First Line Business Practice Location Address:
805 BROADWAY 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:
98660-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-823-0138
Provider Business Practice Location Address Fax Number:
360-823-0141
Provider Enumeration Date:
03/31/2006