Provider First Line Business Practice Location Address:
5512 NE 109TH COURT
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-885-4715
Provider Business Practice Location Address Fax Number:
360-859-3741
Provider Enumeration Date:
04/06/2010