Provider First Line Business Practice Location Address:
1316 NE 99TH 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:
98665-8910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-574-6594
Provider Business Practice Location Address Fax Number:
360-574-2235
Provider Enumeration Date:
09/16/2005