Provider First Line Business Practice Location Address:
214 W BIRCH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99114-2440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-684-6138
Provider Business Practice Location Address Fax Number:
509-684-0884
Provider Enumeration Date:
10/24/2006