Provider First Line Business Practice Location Address: 
311 N. AMBOY AVE.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
YACOLT
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98675
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-798-9875
    Provider Business Practice Location Address Fax Number: 
360-686-4040
    Provider Enumeration Date: 
10/30/2009