Provider First Line Business Practice Location Address: 
2808 COLBY AVE STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EVERETT
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98201-3563
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-317-0157
    Provider Business Practice Location Address Fax Number: 
425-317-0157
    Provider Enumeration Date: 
01/22/2007