Provider First Line Business Practice Location Address:
107 S 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98541-9322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-259-9794
Provider Business Practice Location Address Fax Number:
360-443-7570
Provider Enumeration Date:
06/13/2026