Provider First Line Business Practice Location Address: 
550 17TH AVE
    Provider Second Line Business Practice Location Address: 
SUITE 680
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98122-5788
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-320-6550
    Provider Business Practice Location Address Fax Number: 
206-320-6551
    Provider Enumeration Date: 
12/06/2007