Provider First Line Business Practice Location Address:
844 MT VILLA ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-802-2323
Provider Business Practice Location Address Fax Number:
360-802-6565
Provider Enumeration Date:
05/17/2006