Provider First Line Business Practice Location Address:
6108 1/2 MOTOR AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-588-5228
Provider Business Practice Location Address Fax Number:
253-582-5142
Provider Enumeration Date:
08/16/2006