Provider First Line Business Practice Location Address:
2621 70TH AVENUE WEST
Provider Second Line Business Practice Location Address:
SUITE C
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:
253-564-1006
Provider Business Practice Location Address Fax Number:
253-564-1007
Provider Enumeration Date:
01/04/2019