Provider First Line Business Practice Location Address: 
15704 MILL CREEK BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 18
    Provider Business Practice Location Address City Name: 
MILL CREEK
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98012-1572
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-337-5549
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/19/2006