Provider First Line Business Practice Location Address:
34520 16TH AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98003-6802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-835-9162
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2008