Provider First Line Business Practice Location Address:
151 11TH AVE APT B20
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98122-5459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-553-8140
Provider Business Practice Location Address Fax Number:
360-830-6893
Provider Enumeration Date:
04/15/2026