Provider First Line Business Practice Location Address:
1101 NE 65TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-0219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-907-2631
Provider Business Practice Location Address Fax Number:
360-258-9154
Provider Enumeration Date:
05/31/2008