Provider First Line Business Practice Location Address:
2214 E 13TH ST
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:
98661-4120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-6321
Provider Business Practice Location Address Fax Number:
360-737-2120
Provider Enumeration Date:
09/25/2012