Provider First Line Business Practice Location Address:
1511 E BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-424-4296
Provider Business Practice Location Address Fax Number:
360-568-1654
Provider Enumeration Date:
10/18/2006