Provider First Line Business Practice Location Address:
4109 BRIDGEPORT WAY W STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-459-1920
Provider Business Practice Location Address Fax Number:
253-572-2106
Provider Enumeration Date:
12/29/2006