Provider First Line Business Practice Location Address:
17191 BOTHELL WAY NE
Provider Second Line Business Practice Location Address:
SUITE B203
Provider Business Practice Location Address City Name:
LAKE FOREST PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-367-6069
Provider Business Practice Location Address Fax Number:
206-367-6319
Provider Enumeration Date:
10/10/2006