Provider First Line Business Practice Location Address:
33431-13TH PLACE SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-874-7646
Provider Business Practice Location Address Fax Number:
253-838-8364
Provider Enumeration Date:
08/29/2005