Provider First Line Business Practice Location Address:
11600 SE MILL PLAIN BLVD
Provider Second Line Business Practice Location Address:
SUITE 3J
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98684-5083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-253-6674
Provider Business Practice Location Address Fax Number:
360-253-8670
Provider Enumeration Date:
01/25/2008