Provider First Line Business Practice Location Address: 
17722 TALBOT RD S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RENTON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98055-5744
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-271-4303
    Provider Business Practice Location Address Fax Number: 
425-271-2566
    Provider Enumeration Date: 
03/22/2011