Provider First Line Business Practice Location Address: 
6604 198TH PL SW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LYNNWOOD
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98036-5901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-640-7592
    Provider Business Practice Location Address Fax Number: 
425-640-7592
    Provider Enumeration Date: 
10/30/2009