Provider First Line Business Practice Location Address:
5307 32ND AVE S APT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98118-6107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-548-2979
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/02/2026