Provider First Line Business Practice Location Address:
3516 S 47TH 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:
98409-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-462-1612
Provider Business Practice Location Address Fax Number:
253-572-7727
Provider Enumeration Date:
11/04/2025