Provider First Line Business Practice Location Address:
7025 27TH ST WEST
Provider Second Line Business Practice Location Address:
SUITE #4
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-5528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-565-1019
Provider Business Practice Location Address Fax Number:
535-565-0279
Provider Enumeration Date:
01/13/2009