Provider First Line Business Practice Location Address:
215 NW 78TH STREET
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:
98665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-693-2577
Provider Business Practice Location Address Fax Number:
360-693-0926
Provider Enumeration Date:
08/31/2006