Provider First Line Business Practice Location Address: 
1125 E OLIVE ST STE B
    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: 
98122-8406
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-972-5978
    Provider Business Practice Location Address Fax Number: 
206-322-9169
    Provider Enumeration Date: 
04/06/2006