Provider First Line Business Practice Location Address: 
11117 NE 109TH LN APT N203
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KIRKLAND
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98033-5093
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
603-667-6583
    Provider Business Practice Location Address Fax Number: 
425-487-2004
    Provider Enumeration Date: 
07/06/2012