Provider First Line Business Practice Location Address:
11912 NE FOURTH PLAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682-5642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-944-8368
Provider Business Practice Location Address Fax Number:
360-944-6555
Provider Enumeration Date:
06/26/2012