Provider First Line Business Practice Location Address: 
3824 195TH AVE SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SNOHOMISH
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98290-7427
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
541-409-2242
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/10/2016