Provider First Line Business Practice Location Address:
3015 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-627-1489
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2006