Provider First Line Business Practice Location Address:
140 LAKESIDE AVE # A73
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98122-6551
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-298-5392
Provider Business Practice Location Address Fax Number:
206-316-1357
Provider Enumeration Date:
10/14/2013