Provider First Line Business Practice Location Address:
13510 NE 84TH ST
Provider Second Line Business Practice Location Address:
SUITE #105
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98682-3092
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-0000
Provider Business Practice Location Address Fax Number:
360-896-6264
Provider Enumeration Date:
09/07/2006