Provider First Line Business Practice Location Address:
201 E 19TH ST
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:
98663-3301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-750-1575
Provider Business Practice Location Address Fax Number:
360-750-1898
Provider Enumeration Date:
03/30/2009