Provider First Line Business Practice Location Address:
5305 E 18TH ST
Provider Second Line Business Practice Location Address:
SUITE 224
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-6583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-550-8002
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2010