Provider First Line Business Practice Location Address:
1412 SW 43RD ST
Provider Second Line Business Practice Location Address:
IDC MEDICAL PLAZA, #109
Provider Business Practice Location Address City Name:
RENTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98057-4803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-277-8767
Provider Business Practice Location Address Fax Number:
253-277-8769
Provider Enumeration Date:
08/22/2011