Provider First Line Business Practice Location Address:
775 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
COLVILLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99114-2514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-684-4586
Provider Business Practice Location Address Fax Number:
509-685-1043
Provider Enumeration Date:
02/28/2007