Provider First Line Business Practice Location Address:
101 N PARK STREET
Provider Second Line Business Practice Location Address:
PO
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:
509-935-4988
Provider Business Practice Location Address Fax Number:
509-935-4985
Provider Enumeration Date:
05/13/2016