Provider First Line Business Practice Location Address:
823 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
SUMNER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98390-1155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-826-4554
Provider Business Practice Location Address Fax Number:
253-826-0014
Provider Enumeration Date:
08/10/2006