Provider First Line Business Practice Location Address:
15610 89TH STREET COURT KP N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEBAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98349-9551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-884-9221
Provider Business Practice Location Address Fax Number:
253-884-5523
Provider Enumeration Date:
09/21/2006