Provider First Line Business Practice Location Address: 
12704 76TH AVE S
    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: 
98178-4811
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-839-3540
    Provider Business Practice Location Address Fax Number: 
425-277-1566
    Provider Enumeration Date: 
09/28/2017