Provider First Line Business Practice Location Address:
2215 BROADWAY
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:
98663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-906-7156
Provider Business Practice Location Address Fax Number:
360-696-3658
Provider Enumeration Date:
09/27/2006