Provider First Line Business Practice Location Address:
2850 NW 56TH ST APT 307
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:
98107-4208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-850-0339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2026