Provider First Line Business Practice Location Address: 
209 4TH AVE E
    Provider Second Line Business Practice Location Address: 
STE. 209
    Provider Business Practice Location Address City Name: 
OLYMPIA
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98501-6966
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-943-1947
    Provider Business Practice Location Address Fax Number: 
360-943-1655
    Provider Enumeration Date: 
12/01/2014