Provider First Line Business Practice Location Address: 
4547 8TH AVE NE
    Provider Second Line Business Practice Location Address: 
APT 311
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98105-6702
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
603-391-6259
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/27/2014