Provider First Line Business Practice Location Address: 
17641 153RD WAY SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
YELM
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98597-9153
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-480-0056
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/29/2015