Provider First Line Business Practice Location Address: 
275 SW 160TH ST STE 201
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BURIEN
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98166-3003
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-244-4263
    Provider Business Practice Location Address Fax Number: 
206-244-8703
    Provider Enumeration Date: 
05/29/2019