Provider First Line Business Practice Location Address: 
16810 108TH AVE SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RENTON
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98055-5413
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-227-0111
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/01/2011