Provider First Line Business Practice Location Address: 
2349 YALE AVE E APT 5
    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: 
98102-3336
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-286-9170
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/08/2022