Provider First Line Business Practice Location Address:
5520 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98467-2041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-566-7166
Provider Business Practice Location Address Fax Number:
253-564-8034
Provider Enumeration Date:
11/21/2006