Provider First Line Business Practice Location Address:
1503 NE 78TH ST
Provider Second Line Business Practice Location Address:
STE 9
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-9668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-573-5500
Provider Business Practice Location Address Fax Number:
360-573-9075
Provider Enumeration Date:
06/16/2005