Provider First Line Business Practice Location Address:
5250 BRIDGEPORT WAY W.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-565-1960
Provider Business Practice Location Address Fax Number:
253-565-1996
Provider Enumeration Date:
09/07/2017