Provider First Line Business Practice Location Address: 
21429 44TH AVE W UNIT 27
    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: 
98043-3514
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-696-3436
    Provider Business Practice Location Address Fax Number: 
425-361-1521
    Provider Enumeration Date: 
06/11/2024