Provider First Line Business Practice Location Address:
3906 S 12TH ST UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-327-1147
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2026