Provider First Line Business Practice Location Address: 
22619 SE 64TH PL STE 210
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ISSAQUAH
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98027-5342
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-369-9116
    Provider Business Practice Location Address Fax Number: 
425-369-8997
    Provider Enumeration Date: 
08/22/2016