Provider First Line Business Practice Location Address:
301 E CLAY AVE STE 219
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:
99109-8936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-936-6822
Provider Business Practice Location Address Fax Number:
509-936-4885
Provider Enumeration Date:
01/13/2016