Provider First Line Business Practice Location Address: 
1614 S MILDRED ST
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
TACOMA
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98465-1613
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-564-4233
    Provider Business Practice Location Address Fax Number: 
253-564-9451
    Provider Enumeration Date: 
10/24/2006