Provider First Line Business Practice Location Address:
303 N 2ND STREET W
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:
99109-9203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-4108
Provider Business Practice Location Address Fax Number:
509-935-8750
Provider Enumeration Date:
09/28/2006