Provider First Line Business Practice Location Address:
110 S. THIRD STREET E.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-4925
Provider Business Practice Location Address Fax Number:
509-935-4082
Provider Enumeration Date:
08/31/2016