Provider First Line Business Practice Location Address:
12211 EDGEWOOD AVE SW
Provider Second Line Business Practice Location Address:
APT.# 12
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98498-1201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-330-1583
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/11/2015