Provider First Line Business Practice Location Address:
4555 39TH AVE SW APT B621
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:
98116-4365
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-718-4664
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/31/2026