Provider First Line Business Practice Location Address:
1300 TACOMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-686-2201
Provider Business Practice Location Address Fax Number:
509-686-4052
Provider Enumeration Date:
07/02/2006