Provider First Line Business Practice Location Address:
9657 FIRDALE AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98020-6519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-629-4065
Provider Business Practice Location Address Fax Number:
360-698-9296
Provider Enumeration Date:
10/07/2010