Provider First Line Business Practice Location Address: 
5400 MACARTHUR BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VANCOUVER
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98661-7049
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-696-5100
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/05/2021