Provider First Line Business Practice Location Address:
301 E CLAY AVE STE 201
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:
509-935-4808
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/16/2019