Provider First Line Business Practice Location Address:
16017 NE 79TH WAY
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:
98682-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-605-8930
Provider Business Practice Location Address Fax Number:
360-251-0313
Provider Enumeration Date:
05/04/2026