Provider First Line Business Practice Location Address: 
2743 CALIFORNIA AVE SW
    Provider Second Line Business Practice Location Address: 
SUITE 201
    Provider Business Practice Location Address City Name: 
SEATTLE
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98116
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
206-938-9380
    Provider Business Practice Location Address Fax Number: 
206-938-9384
    Provider Enumeration Date: 
10/03/2006