Provider First Line Business Practice Location Address:
7706 45TH STREET CT W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UNIVERSITY PLACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98466-3022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-409-3024
Provider Business Practice Location Address Fax Number:
206-826-1814
Provider Enumeration Date:
03/26/2026