Provider First Line Business Practice Location Address: 
2115 SE 192ND AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CAMAS
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98607-7479
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-833-2868
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/20/2013