Provider First Line Business Practice Location Address:
1203 NE 92ND ST
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:
98115-3134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-708-1795
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/25/2012