Provider First Line Business Practice Location Address:
22626 NE INGLEWOOD HILL ROAD
Provider Second Line Business Practice Location Address:
APARTMENT #1033
Provider Business Practice Location Address City Name:
SAMMAMISH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98074-5003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-799-8565
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2007