Provider First Line Business Practice Location Address: 
4330 N VISSCHER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TACOMA
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98407-1916
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-571-6907
    Provider Business Practice Location Address Fax Number: 
253-571-6922
    Provider Enumeration Date: 
09/19/2012