Provider First Line Business Practice Location Address:
1223 SW 126TH ST APT D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURIEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98146-3078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-519-4824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2026