Provider First Line Business Practice Location Address: 
406 BURNETT AVE S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RENTON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98057-2551
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-271-5705
    Provider Business Practice Location Address Fax Number: 
425-271-0165
    Provider Enumeration Date: 
01/16/2007