Provider First Line Business Practice Location Address: 
9618 GRAVELLY LAKE DR SW
    Provider Second Line Business Practice Location Address: 
#201
    Provider Business Practice Location Address City Name: 
LAKEWOOD
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98499-1575
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-777-2321
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/28/2009