Provider First Line Business Practice Location Address: 
33930 WEYERHAEUSER WAY S STE 220
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FEDERAL WAY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98001-9772
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-752-7320
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/14/2018