Provider First Line Business Practice Location Address:
2206 S 128TH ST UNIT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURIEN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98168-3053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-380-8086
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2026