Provider First Line Business Practice Location Address: 
10116 116TH ST E
    Provider Second Line Business Practice Location Address: 
SUITE 204-B
    Provider Business Practice Location Address City Name: 
PUYALLUP
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98373-3543
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-237-4188
    Provider Business Practice Location Address Fax Number: 
253-604-4533
    Provider Enumeration Date: 
10/24/2006