Provider First Line Business Practice Location Address:
3502 NE 192ND PL
Provider Second Line Business Practice Location Address:
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:
98155-2628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
454-545-4545
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2026