Provider First Line Business Practice Location Address:
11719 NE 95TH ST
Provider Second Line Business Practice Location Address:
#F
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-896-3188
Provider Business Practice Location Address Fax Number:
360-896-3122
Provider Enumeration Date:
09/21/2007