Provider First Line Business Practice Location Address:
411 SE ELLSWORTH RD
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:
98664-5113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-504-1816
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/19/2026