Provider First Line Business Practice Location Address:
139 FIRST AVENUE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLE ROCK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98611-0160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-274-2353
Provider Business Practice Location Address Fax Number:
360-274-2354
Provider Enumeration Date:
12/18/2007