Provider First Line Business Practice Location Address:
3670A 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:
98466-4413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-473-2215
Provider Business Practice Location Address Fax Number:
253-471-8892
Provider Enumeration Date:
07/24/2006