Provider First Line Business Practice Location Address:
112 25TH AVE E APT 201
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:
98112-5471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-830-0199
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/25/2026