Provider First Line Business Practice Location Address:
819 S 13TH ST
Provider Second Line Business Practice Location Address:
SRC RESIDENCY CLINIC
Provider Business Practice Location Address City Name:
MOUNT VERNON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98274-4112
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-814-6230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2012