Provider First Line Business Practice Location Address:
101 BOLSTAD AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98631
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-642-2349
Provider Business Practice Location Address Fax Number:
360-642-8786
Provider Enumeration Date:
10/19/2006