Provider First Line Business Practice Location Address:
4111 BRIDGEPORT WAY WEST
Provider Second Line Business Practice Location Address:
SUITE A
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-582-9103
Provider Business Practice Location Address Fax Number:
253-460-3082
Provider Enumeration Date:
11/07/2006