Provider First Line Business Practice Location Address:
9040 JACKSON AVE MCHJ-QSD-C CREDENTIALS OFFICE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-3885
Provider Business Practice Location Address Fax Number:
253-968-1996
Provider Enumeration Date:
12/14/2006