Provider First Line Business Practice Location Address:
3516 S 47TH ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98409-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-475-2160
Provider Business Practice Location Address Fax Number:
253-475-0902
Provider Enumeration Date:
09/25/2009