Provider First Line Business Practice Location Address:
1206 S 11TH ST
Provider Second Line Business Practice Location Address:
SUITE 15A
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4099
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-222-9621
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2007