Provider First Line Business Practice Location Address:
1420 S 12TH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-376-5552
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2007