Provider First Line Business Practice Location Address:
1427 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-3613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-825-4466
Provider Business Practice Location Address Fax Number:
360-825-2064
Provider Enumeration Date:
10/28/2008