Provider First Line Business Practice Location Address:
32030 23RD AVE S
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:
98003-6031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-946-4852
Provider Business Practice Location Address Fax Number:
253-946-4862
Provider Enumeration Date:
08/23/2005