Provider First Line Business Practice Location Address:
5231 39TH AVE S APT 312
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:
98118-6170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-889-5993
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2025