Provider First Line Business Practice Location Address:
6004 12TH AVE S APT 13A
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:
98108-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-882-7169
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2024