Provider First Line Business Practice Location Address: 
19853 STATE ROUTE 2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MONROE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98272
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-794-9055
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/18/2012