Provider First Line Business Practice Location Address:
518 E CLAY 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:
99109-8947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-6004
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/27/2024