Provider First Line Business Practice Location Address:
10312 120TH STREET EAST
Provider Second Line Business Practice Location Address:
SUITE #3
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-848-6887
Provider Business Practice Location Address Fax Number:
253-604-0312
Provider Enumeration Date:
05/02/2008