Provider First Line Business Practice Location Address:
12214 SE MILL PLAIN BLVD
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684-6019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-885-1930
Provider Business Practice Location Address Fax Number:
360-885-1930
Provider Enumeration Date:
05/27/2005