Provider First Line Business Practice Location Address: 
22500 SE 64TH PL
    Provider Second Line Business Practice Location Address: 
BUILDING G, SUITE 115
    Provider Business Practice Location Address City Name: 
ISSAQUAH
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98027-8111
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-441-6075
    Provider Business Practice Location Address Fax Number: 
425-746-2471
    Provider Enumeration Date: 
04/06/2006