Provider First Line Business Practice Location Address:
100 W SOUTH 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:
99109-9684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-8111
Provider Business Practice Location Address Fax Number:
509-626-9917
Provider Enumeration Date:
03/30/2021