Provider First Line Business Practice Location Address:
19500 10TH AVE. NE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
POULBO
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98370
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-779-4005
Provider Business Practice Location Address Fax Number:
360-394-1707
Provider Enumeration Date:
04/23/2007