Provider First Line Business Practice Location Address: 
2320 FREEWAY DRIVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOUNT VERNON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98273
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-814-6800
    Provider Business Practice Location Address Fax Number: 
360-814-6917
    Provider Enumeration Date: 
10/03/2011