Provider First Line Business Practice Location Address: 
35999 16TH AVE S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FEDERAL WAY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98003-7414
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-945-3170
    Provider Business Practice Location Address Fax Number: 
253-945-2177
    Provider Enumeration Date: 
08/20/2009