Provider First Line Business Practice Location Address:
3009 S 40TH ST
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:
98409-5632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-238-1678
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2026