Provider First Line Business Practice Location Address:
117 E 39TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98663-2229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-694-7931
Provider Business Practice Location Address Fax Number:
360-694-0722
Provider Enumeration Date:
02/08/2012