Provider First Line Business Practice Location Address: 
4560 KLAHANIE DR SE STE 400
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAMMAMISH
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98029-5812
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-394-0620
    Provider Business Practice Location Address Fax Number: 
425-394-0622
    Provider Enumeration Date: 
11/25/2015