Provider First Line Business Practice Location Address:
4103 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-565-4474
Provider Business Practice Location Address Fax Number:
253-565-6848
Provider Enumeration Date:
07/30/2008