Provider First Line Business Practice Location Address:
2620 SW DAKOTA ST APT 2
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:
98126-2595
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-536-0321
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/15/2026