Provider First Line Business Practice Location Address: 
5059 FERNDALE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FERNDALE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98248-9122
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-815-1234
    Provider Business Practice Location Address Fax Number: 
360-255-4210
    Provider Enumeration Date: 
11/26/2014