Provider First Line Business Practice Location Address:
19616 61ST PL NE APT 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENMORE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98028-1954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-794-1038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2025