Provider First Line Business Practice Location Address:
6499 W COMMERCIAL PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATHDRUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83858-6711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-687-8156
Provider Business Practice Location Address Fax Number:
208-687-8510
Provider Enumeration Date:
05/25/2006