Provider First Line Business Practice Location Address:
3614 72ND AVENUE CT 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:
98466-4407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-450-7669
Provider Business Practice Location Address Fax Number:
253-753-1825
Provider Enumeration Date:
06/01/2005