Provider First Line Business Practice Location Address: 
5003 25TH AVE SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LACEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98503-3352
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-790-3770
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/19/2011