Provider First Line Business Practice Location Address: 
147 ROGERS ST NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OLYMPIA
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98502-5343
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-754-1396
    Provider Business Practice Location Address Fax Number: 
360-753-4288
    Provider Enumeration Date: 
08/27/2013