Provider First Line Business Practice Location Address: 
7500 212TH ST SW STE 101
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EDMONDS
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98026-7614
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-776-6966
    Provider Business Practice Location Address Fax Number: 
425-776-6969
    Provider Enumeration Date: 
01/23/2018