Provider First Line Business Practice Location Address:
12601 68TH AVE S APT 22D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98178-4164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-372-3605
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/12/2025