Provider First Line Business Practice Location Address:
107 W MAIN AVE
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:
99109-9257
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-229-5504
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2012