Provider First Line Business Practice Location Address:
300 E COLLEGE WAY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98273-5429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-428-6677
Provider Business Practice Location Address Fax Number:
369-428-7635
Provider Enumeration Date:
10/21/2005