Provider First Line Business Practice Location Address:
410 E KING ST
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:
99109-0137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-935-8711
Provider Business Practice Location Address Fax Number:
509-935-4882
Provider Enumeration Date:
12/11/2006