Provider First Line Business Practice Location Address:
8012 112TH ST COURT EAST
Provider Second Line Business Practice Location Address:
SUITE 340
Provider Business Practice Location Address City Name:
PUYALLUP
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98373-7856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-840-0789
Provider Business Practice Location Address Fax Number:
253-841-6832
Provider Enumeration Date:
10/10/2006