Provider First Line Business Practice Location Address:
110 OREGON AVE S.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-642-1250
Provider Business Practice Location Address Fax Number:
883-082-8788
Provider Enumeration Date:
07/25/2012