Provider First Line Business Practice Location Address: 
11747 NE 1ST ST
    Provider Second Line Business Practice Location Address: 
SUITE 330
    Provider Business Practice Location Address City Name: 
BELLEVUE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98005-3053
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-462-9647
    Provider Business Practice Location Address Fax Number: 
425-462-9333
    Provider Enumeration Date: 
04/11/2013