Provider First Line Business Practice Location Address:
110 COLUMBIA ST
Provider Second Line Business Practice Location Address:
SUITE 115
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98660-3159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-2857
Provider Business Practice Location Address Fax Number:
360-737-0743
Provider Enumeration Date:
07/13/2006