Provider First Line Business Practice Location Address: 
8424 NE 150TH PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KENMORE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98028-4746
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-499-7147
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/12/2014