Provider First Line Business Practice Location Address:
4606 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-4200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-565-3551
Provider Business Practice Location Address Fax Number:
253-565-4535
Provider Enumeration Date:
11/09/2005