Provider First Line Business Practice Location Address:
1703 PACIFIC AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98631-3400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-642-3214
Provider Business Practice Location Address Fax Number:
360-642-5333
Provider Enumeration Date:
06/09/2005