Provider First Line Business Practice Location Address:
2728 61ST AVE SW APT 29
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:
98116-2866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-730-6419
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/26/2026