Provider First Line Business Practice Location Address:
5715 48TH ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98467-3677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-281-5774
Provider Business Practice Location Address Fax Number:
253-565-0658
Provider Enumeration Date:
08/17/2012