Provider First Line Business Practice Location Address:
5424 BALLARD AVENUE NW
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-989-3389
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2012