Provider First Line Business Practice Location Address: 
24080 SE KENT KANGLEY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MAPLE VALLEY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98038-6851
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-372-7680
    Provider Business Practice Location Address Fax Number: 
253-372-7681
    Provider Enumeration Date: 
04/21/2019