Provider First Line Business Practice Location Address: 
5625 POPLAR PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FERNDALE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98248-9178
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
901-335-1271
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/13/2020