Provider First Line Business Practice Location Address:
30221 19TH 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:
98003-5182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-504-8128
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2026