Provider First Line Business Practice Location Address:
1522 HARDING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ENUMCLAW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98022-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-367-6158
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2011