Provider First Line Business Practice Location Address:
301 E CLAY AVE
Provider Second Line Business Practice Location Address:
SUITE #220
Provider Business Practice Location Address City Name:
CHEWELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99109-8936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-4023
Provider Business Practice Location Address Fax Number:
509-935-4026
Provider Enumeration Date:
04/05/2007