Provider First Line Business Practice Location Address:
10401 NE FOURTH PLAIN RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98662-6308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-892-5142
Provider Business Practice Location Address Fax Number:
360-892-2157
Provider Enumeration Date:
11/29/2006