Provider First Line Business Practice Location Address:
814 NE 87TH AVE
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:
98664-1915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-910-1522
Provider Business Practice Location Address Fax Number:
360-326-1522
Provider Enumeration Date:
01/27/2009