Provider First Line Business Practice Location Address:
1307 NE 78TH ST
Provider Second Line Business Practice Location Address:
SUITE B13
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-9670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-574-0900
Provider Business Practice Location Address Fax Number:
360-573-6338
Provider Enumeration Date:
05/27/2009