Provider First Line Business Practice Location Address:
37 HIGHWAY 57
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRIEST RIVER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83856-6559
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-4855
Provider Business Practice Location Address Fax Number:
208-448-2467
Provider Enumeration Date:
10/09/2009