Provider First Line Business Practice Location Address:
4007 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-565-7529
Provider Business Practice Location Address Fax Number:
253-399-2508
Provider Enumeration Date:
12/05/2005