Provider First Line Business Practice Location Address:
1605 NW 60TH ST
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:
98663-1122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-740-6196
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/26/2025