Provider First Line Business Practice Location Address:
18002 LIPOMA FIRS E UNIT G104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98374-9008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-478-0945
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2020