Provider First Line Business Practice Location Address:
4542 S LUCILE ST
Provider Second Line Business Practice Location Address:
APT B
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98118-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-395-4495
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2016