Provider First Line Business Practice Location Address: 
310 31ST AVE SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PUYALLUP
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98374-1232
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-770-9889
    Provider Business Practice Location Address Fax Number: 
253-770-9983
    Provider Enumeration Date: 
08/18/2014