Provider First Line Business Practice Location Address: 
19005 SE 34TH ST
    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: 
98683-1450
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-726-6720
    Provider Business Practice Location Address Fax Number: 
360-726-6729
    Provider Enumeration Date: 
01/27/2023