Provider First Line Business Practice Location Address: 
619 97TH AVE SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKE STEVENS
    Provider Business Practice Location Address State Name: 
WA
    Provider Business Practice Location Address Postal Code: 
98258-3910
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
425-232-8854
    Provider Business Practice Location Address Fax Number: 
425-335-4328
    Provider Enumeration Date: 
02/20/2007