Provider First Line Business Practice Location Address:
12503 SE MILL PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 119A
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-718-7747
Provider Business Practice Location Address Fax Number:
360-852-8041
Provider Enumeration Date:
06/11/2009