Provider First Line Business Practice Location Address:
224 E 5TH AVE APT A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
METALINE FALLS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99153-9730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-309-4494
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2016