Provider First Line Business Practice Location Address: 
3939 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: 
98118-3505
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-987-1337
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/21/2006