Provider First Line Business Practice Location Address:
5512 NE 109TH CT
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-910-8004
Provider Business Practice Location Address Fax Number:
360-882-3006
Provider Enumeration Date:
07/12/2006