Provider First Line Business Practice Location Address:
4515 S OTHELLO ST
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:
98118-3846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-239-8019
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2012