Provider First Line Business Practice Location Address:
1641 E POLSTON AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-7852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-457-4208
Provider Business Practice Location Address Fax Number:
208-457-4197
Provider Enumeration Date:
06/12/2006