Provider First Line Business Practice Location Address:
3912 S LUCILE ST
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:
98118-2258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-517-0781
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2019