Provider First Line Business Practice Location Address:
2728 E MAIN AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98372-3198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-848-0131
Provider Business Practice Location Address Fax Number:
253-840-6787
Provider Enumeration Date:
09/15/2005