Provider First Line Business Practice Location Address:
16728 140TH AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98374-9535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-634-1036
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/21/2026