Provider First Line Business Practice Location Address:
9574 LAKE SHORE BLVD NE
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:
98115-2644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-940-2879
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/20/2011