Provider First Line Business Practice Location Address:
1110 E 29TH ST UNIT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98404-3202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-208-3169
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2026