Provider First Line Business Practice Location Address:
8507 SOUTH 5TH STREET
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-887-9494
Provider Business Practice Location Address Fax Number:
360-887-9498
Provider Enumeration Date:
09/21/2006