Provider First Line Business Practice Location Address: 
2000 SO 314TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FEDERAL WAY
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98003
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
253-529-7168
    Provider Business Practice Location Address Fax Number: 
253-529-7237
    Provider Enumeration Date: 
10/26/2009