Provider First Line Business Practice Location Address:
4107 N ORCHARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98407-4243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-649-1579
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2026