Provider First Line Business Practice Location Address:
4109 SW BRADFORD ST
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:
98116-3828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-339-6709
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2026