Provider First Line Business Practice Location Address:
610 E MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEWELAH
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99109-1166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-9246
Provider Business Practice Location Address Fax Number:
509-935-9245
Provider Enumeration Date:
01/25/2007