Provider First Line Business Practice Location Address:
3840 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-460-2875
Provider Business Practice Location Address Fax Number:
253-460-2985
Provider Enumeration Date:
10/18/2008