Provider First Line Business Practice Location Address: 
7231 EAGLEFIELD DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARLINGTON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98223-5984
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-408-0241
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/15/2011