Provider First Line Business Practice Location Address: 
643 SW 152ND ST
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
BURIEN
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98166-2261
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-214-0838
    Provider Business Practice Location Address Fax Number: 
206-420-1558
    Provider Enumeration Date: 
08/14/2014