Provider First Line Business Practice Location Address:
4401 BRIDGEPORT WAY 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:
98466-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-564-4157
Provider Business Practice Location Address Fax Number:
253-564-4813
Provider Enumeration Date:
11/10/2010