Provider First Line Business Practice Location Address: 
3805 108TH AVE NE
    Provider Second Line Business Practice Location Address: 
SUITE 120
    Provider Business Practice Location Address City Name: 
BELLEVUE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98004-7613
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-803-0989
    Provider Business Practice Location Address Fax Number: 
425-739-9485
    Provider Enumeration Date: 
07/03/2007