Provider First Line Business Practice Location Address:
13317 NE 12TH AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98685-2727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-573-3937
Provider Business Practice Location Address Fax Number:
360-574-3290
Provider Enumeration Date:
05/31/2005