Provider First Line Business Practice Location Address:
5501 215TH ST SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTLAKE TERRACE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98043-3044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-707-2791
Provider Business Practice Location Address Fax Number:
425-361-7313
Provider Enumeration Date:
08/29/2025