Provider First Line Business Practice Location Address: 
738 N 179TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SHORELINE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98133-4730
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-713-2879
    Provider Business Practice Location Address Fax Number: 
206-546-1085
    Provider Enumeration Date: 
05/09/2007