Provider First Line Business Practice Location Address:
406 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:
99109-8972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-8441
Provider Business Practice Location Address Fax Number:
509-935-8406
Provider Enumeration Date:
08/20/2006