Provider First Line Business Practice Location Address:
6818 NE FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-7357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-694-3007
Provider Business Practice Location Address Fax Number:
360-735-7420
Provider Enumeration Date:
10/07/2011