Provider First Line Business Practice Location Address:
312 4TH ST SE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-435-9005
Provider Business Practice Location Address Fax Number:
253-435-9007
Provider Enumeration Date:
01/12/2006