Provider First Line Business Practice Location Address:
115 N YAKIMA AVE APT 302
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:
98403-3402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-359-1947
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2026