Provider First Line Business Practice Location Address:
13025 NE FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-718-8240
Provider Business Practice Location Address Fax Number:
360-718-8241
Provider Enumeration Date:
10/21/2008