Provider First Line Business Practice Location Address: 
15214 FERN ST SW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKEWOOD
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98498-1008
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
251-753-3192
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/04/2025