Provider First Line Business Practice Location Address:
8721 116TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98498-3650
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-588-2144
Provider Business Practice Location Address Fax Number:
253-475-3204
Provider Enumeration Date:
04/16/2026