Provider First Line Business Practice Location Address:
405 E LINCOLN 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:
99109-8955
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-685-6800
Provider Business Practice Location Address Fax Number:
509-935-4860
Provider Enumeration Date:
01/29/2013