Provider First Line Business Practice Location Address: 
9230 215TH ST SW
    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: 
98020-3929
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
509-868-9691
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/20/2017