Provider First Line Business Practice Location Address:
29 S 342ND PL APT C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-4417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-376-8154
Provider Business Practice Location Address Fax Number:
253-376-8154
Provider Enumeration Date:
12/27/2007