Provider First Line Business Practice Location Address:
306 N PARK 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:
99109-8971
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-2020
Provider Business Practice Location Address Fax Number:
509-935-6795
Provider Enumeration Date:
10/30/2018