Provider First Line Business Practice Location Address: 
18303 ANDOVER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EDMONDS
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98026-5429
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-719-0813
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/11/2006