Provider First Line Business Practice Location Address: 
1928 43RD AVE E APT 5
    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: 
98112-6217
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
360-581-3660
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/03/2014