Provider First Line Business Practice Location Address:
11818 SE MILL PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684-5089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-896-5150
Provider Business Practice Location Address Fax Number:
360-896-0253
Provider Enumeration Date:
11/10/2010