Provider First Line Business Practice Location Address:
712 YAKIMA AVE APT 3712S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4817
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-973-5710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2025