Provider First Line Business Practice Location Address:
100 E 13TH ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98660-3326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-1646
Provider Business Practice Location Address Fax Number:
360-571-8460
Provider Enumeration Date:
02/28/2006