Provider First Line Business Practice Location Address: 
2026 54TH AVE E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FIFE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98424-1904
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-922-0450
    Provider Business Practice Location Address Fax Number: 
253-926-1720
    Provider Enumeration Date: 
09/21/2011