Provider First Line Business Practice Location Address:
1306 N 48TH ST APT 2
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:
98103-6780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-661-1457
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2025