Provider First Line Business Practice Location Address:
1222 NE 94TH 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:
98115-3137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-909-0571
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2025