Provider First Line Business Practice Location Address:
806 N WEST ST
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:
99109-9188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-640-0875
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/20/2022