Provider First Line Business Practice Location Address:
19102 SR 410 E SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNEY LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98391
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-863-6378
Provider Business Practice Location Address Fax Number:
253-863-6429
Provider Enumeration Date:
01/13/2011