Provider First Line Business Practice Location Address: 
10111 S TACOMA WAY STE D2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKEWOOD
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98499-5424
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
800-225-9080
    Provider Business Practice Location Address Fax Number: 
866-434-3610
    Provider Enumeration Date: 
08/05/2006