Provider First Line Business Practice Location Address:
5353 S FOUNTAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98178-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-207-6307
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2025