Provider First Line Business Practice Location Address:
316 E FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98663-3074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-993-0599
Provider Business Practice Location Address Fax Number:
360-993-0599
Provider Enumeration Date:
11/20/2006