Provider First Line Business Practice Location Address:
13607 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:
98682-5838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-433-5727
Provider Business Practice Location Address Fax Number:
360-314-2855
Provider Enumeration Date:
08/21/2025