Provider First Line Business Practice Location Address:
3208 NE 54TH ST
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:
360-693-8181
Provider Business Practice Location Address Fax Number:
360-750-9069
Provider Enumeration Date:
10/13/2006