Provider First Line Business Practice Location Address:
124 N 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-3525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-428-7883
Provider Business Practice Location Address Fax Number:
360-424-7223
Provider Enumeration Date:
12/12/2006