Provider First Line Business Practice Location Address:
5121 17TH AVE NW APT 25
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:
98107-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-883-3407
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2025