Provider First Line Business Practice Location Address:
12320 ROOSEVELT WAY NE APT 105
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:
98125-4846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-295-2473
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2025