Provider First Line Business Practice Location Address:
200 E 22ND ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98663-3266
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-693-8439
Provider Business Practice Location Address Fax Number:
360-696-4811
Provider Enumeration Date:
05/10/2006