Provider First Line Business Practice Location Address: 
1825 SE 164TH AVE
    Provider Second Line Business Practice Location Address: 
SUITE 119
    Provider Business Practice Location Address City Name: 
VANCOUVER
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98683-8602
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-892-0100
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/06/2012