Provider First Line Business Practice Location Address: 
2440 42ND AVE E
    Provider Second Line Business Practice Location Address: 
#240
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98112-2532
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-860-8569
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/24/2007