Provider First Line Business Practice Location Address: 
21123 SMOKEY POINT BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARLINGTON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98223-4224
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-652-9640
    Provider Business Practice Location Address Fax Number: 
360-652-2093
    Provider Enumeration Date: 
09/01/2009