Provider First Line Business Practice Location Address:
5511 112TH AVENUE CT E
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-5942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-845-4655
Provider Business Practice Location Address Fax Number:
253-845-1052
Provider Enumeration Date:
10/13/2006