Provider First Line Business Practice Location Address:
2013 SE 146TH AVE
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:
98683-8428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-453-8642
Provider Business Practice Location Address Fax Number:
360-258-0865
Provider Enumeration Date:
12/27/2025