Provider First Line Business Practice Location Address: 
102-6545 PORTSMOUTH ROAD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NANAIMO
    Provider Business Practice Location Address State Name: 
BC
    Provider Business Practice Location Address Postal Code: 
V9V 1A3
    Provider Business Practice Location Address Country Code: 
CA
    Provider Business Practice Location Address Telephone Number: 
250-824-1724
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/06/2017