Provider First Line Business Practice Location Address:
2323 W NEWTON ST APT 4
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:
98199-4143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-932-7753
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2025