Provider First Line Business Practice Location Address:
5308 BALLARD AVE NW
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98107-4006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-403-8176
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2006