Provider First Line Business Practice Location Address:
13619 8TH AVENUE CT S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98444-3452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-302-5815
Provider Business Practice Location Address Fax Number:
253-446-1245
Provider Enumeration Date:
01/16/2026