Provider First Line Business Practice Location Address: 
1132 10TH AVE E
    Provider Second Line Business Practice Location Address: 
#21
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98102-4358
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
831-334-5241
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/23/2012