Provider First Line Business Practice Location Address: 
4090 GUIDE MERIDIAN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BELLINGHAM
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98226-5517
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-734-0229
    Provider Business Practice Location Address Fax Number: 
360-734-0658
    Provider Enumeration Date: 
08/31/2011