Provider First Line Business Practice Location Address:
12224 53RD STREET CT E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-9241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-973-7677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/16/2010