Provider First Line Business Practice Location Address: 
2348 S TRAIL VIEW CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RIDGEFIELD
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98642-2805
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-953-1247
    Provider Business Practice Location Address Fax Number: 
888-261-6694
    Provider Enumeration Date: 
07/27/2020