Provider First Line Business Practice Location Address:
811 NE 67TH ST
Provider Second Line Business Practice Location Address:
APT 6
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98115-5597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-227-4369
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2009