Provider First Line Business Practice Location Address:
2105 NE 129TH ST
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-573-3611
Provider Business Practice Location Address Fax Number:
360-573-3611
Provider Enumeration Date:
12/18/2009