Provider First Line Business Practice Location Address:
10005 24TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98371-2130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-350-8763
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2011