Provider First Line Business Practice Location Address:
18490 BALLINGER WAY NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE FOREST PARK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98155-4239
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-364-0174
Provider Business Practice Location Address Fax Number:
206-364-0174
Provider Enumeration Date:
03/11/2008