Provider First Line Business Practice Location Address:
22502 NE 139TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUSH PRAIRIE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98606-9409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-784-0914
Provider Business Practice Location Address Fax Number:
360-828-8337
Provider Enumeration Date:
10/13/2014