Provider First Line Business Practice Location Address:
306 EAST MAIN
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:
99109-0050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-6822
Provider Business Practice Location Address Fax Number:
509-935-6822
Provider Enumeration Date:
03/24/2006