Provider First Line Business Practice Location Address:
4717 S 19TH ST STE 102
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:
98405-1167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-534-7800
Provider Business Practice Location Address Fax Number:
253-948-1998
Provider Enumeration Date:
02/04/2026