Provider First Line Business Practice Location Address:
1404 CENTRAL AVE S
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
KENT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98032-7433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-876-7626
Provider Business Practice Location Address Fax Number:
253-876-7621
Provider Enumeration Date:
12/14/2006