Provider First Line Business Practice Location Address:
11104 NE 149TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUSH PRAIRIE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98606-9565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-885-5318
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2012