Provider First Line Business Practice Location Address:
823 W MAIN ST STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMNER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98390-1156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-735-0144
Provider Business Practice Location Address Fax Number:
253-735-0145
Provider Enumeration Date:
09/27/2006