Provider First Line Business Practice Location Address:
1427 JEFFERSON AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-3649
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-825-2701
Provider Business Practice Location Address Fax Number:
360-825-5724
Provider Enumeration Date:
01/15/2007