Provider First Line Business Practice Location Address: 
2221 N TRUMPETER DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MOUNT VERNON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98273-8968
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-540-2265
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/26/2014