Provider First Line Business Practice Location Address: 
12715 BEL RED RD STE 201
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BELLEVUE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98005-2627
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-265-2616
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/14/2016