Provider First Line Business Practice Location Address:
15029 BOTHELL WAY NE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
LAKE FOREST PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155-7663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-364-0075
Provider Business Practice Location Address Fax Number:
206-364-7607
Provider Enumeration Date:
11/15/2005