Provider First Line Business Practice Location Address:
416 NE 87TH AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-1930
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-719-2171
Provider Business Practice Location Address Fax Number:
360-719-2172
Provider Enumeration Date:
07/13/2006