Provider First Line Business Practice Location Address:
543 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98020-3162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-670-8458
Provider Business Practice Location Address Fax Number:
425-740-0991
Provider Enumeration Date:
10/12/2005