Provider First Line Business Practice Location Address:
410 E 20TH ST
Provider Second Line Business Practice Location Address:
SUITE #7
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-608-1806
Provider Business Practice Location Address Fax Number:
360-253-3047
Provider Enumeration Date:
07/19/2006