Provider First Line Business Practice Location Address:
1307B NE 78TH ST.
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-573-1933
Provider Business Practice Location Address Fax Number:
360-571-0143
Provider Enumeration Date:
11/02/2006