Provider First Line Business Practice Location Address: 
9730 3RD AVE NE
    Provider Second Line Business Practice Location Address: 
SUITE #204
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98115-2023
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-524-5700
    Provider Business Practice Location Address Fax Number: 
206-524-0765
    Provider Enumeration Date: 
10/04/2006