Provider First Line Business Practice Location Address: 
10512 NE 68TH ST
    Provider Second Line Business Practice Location Address: 
BLDG C, STE 202
    Provider Business Practice Location Address City Name: 
KIRKLAND
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98033-7002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-552-8207
    Provider Business Practice Location Address Fax Number: 
425-822-3418
    Provider Enumeration Date: 
02/26/2015