Provider First Line Business Practice Location Address:
910 NE MINNEHAHA ST
Provider Second Line Business Practice Location Address:
SUITE 12
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98665-8750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-9461
Provider Business Practice Location Address Fax Number:
360-699-7199
Provider Enumeration Date:
10/20/2006