Provider First Line Business Practice Location Address:
502 NW 199TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEFIELD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98642-5601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-619-1500
Provider Business Practice Location Address Fax Number:
360-619-1559
Provider Enumeration Date:
09/17/2012