Provider First Line Business Practice Location Address:
1601 NE 4TH PLAIN BLVD
Provider Second Line Business Practice Location Address:
BLDG. #17 STE. A-150
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-397-8198
Provider Business Practice Location Address Fax Number:
360-397-8476
Provider Enumeration Date:
03/12/2009