Provider First Line Business Practice Location Address:
34617 11TH PLACE S
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-8706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-838-8516
Provider Business Practice Location Address Fax Number:
253-838-8517
Provider Enumeration Date:
12/06/2007