Provider First Line Business Practice Location Address: 
7000 NE 186TH PL APT 105
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KENMORE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98028-2143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-708-9016
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/22/2014