Provider First Line Business Practice Location Address:
32105 1ST AVE S
Provider Second Line Business Practice Location Address:
SUITE B-5
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-838-2055
Provider Business Practice Location Address Fax Number:
253-874-2992
Provider Enumeration Date:
11/02/2006