Provider First Line Business Practice Location Address:
4230 BRIDGEPORT WAY W STE A
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:
98466-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-212-0272
Provider Business Practice Location Address Fax Number:
253-254-7043
Provider Enumeration Date:
05/29/2026