Provider First Line Business Practice Location Address: 
5335 NE 4TH ST STE 4
    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: 
98059-4831
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-850-1882
    Provider Business Practice Location Address Fax Number: 
425-282-5936
    Provider Enumeration Date: 
07/20/2006