Provider First Line Business Practice Location Address:
13225 N LACEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEAD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99021-9623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-604-1810
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2026