Provider First Line Business Practice Location Address:
119 30TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98144-2501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-566-8030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2026