Provider First Line Business Practice Location Address: 
700 S 320TH ST
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
FEDERAL WAY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98003-4691
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-880-1029
    Provider Business Practice Location Address Fax Number: 
253-322-6203
    Provider Enumeration Date: 
07/30/2014