Provider First Line Business Practice Location Address: 
5413 MERIDIAN AVE N
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98103-6168
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-284-1435
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/07/2011