Provider First Line Business Practice Location Address:
1601 E FOURTH PLAIN BLVD
Provider Second Line Business Practice Location Address:
P3MHADM
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661-3713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-696-4061
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2006