Provider First Line Business Practice Location Address:
24 PRAIRIE GARDENS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUMPTULIPS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-987-2274
Provider Business Practice Location Address Fax Number:
360-987-2275
Provider Enumeration Date:
01/08/2009