Provider First Line Business Practice Location Address: 
2197 SHORE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FREELAND
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98249-9595
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-419-7907
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/21/2020