Provider First Line Business Practice Location Address:
10501 NE HIGHWAY 99 STE 23
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-5698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-573-9669
Provider Business Practice Location Address Fax Number:
360-573-0448
Provider Enumeration Date:
12/28/2006