Provider First Line Business Practice Location Address:
10024 140TH STREET CT E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98373-2567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-697-6465
Provider Business Practice Location Address Fax Number:
253-733-1221
Provider Enumeration Date:
09/18/2026