Provider First Line Business Practice Location Address:
12612 NE 115TH WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682-8705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-298-3787
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2026