Provider First Line Business Practice Location Address:
1404 NE 134TH STREET
Provider Second Line Business Practice Location Address:
SUTIE 180F
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-784-2777
Provider Business Practice Location Address Fax Number:
615-827-2816
Provider Enumeration Date:
10/02/2009