Provider First Line Business Practice Location Address:
5486 HIGHWAY 2
Provider Second Line Business Practice Location Address:
STE. 102
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-5049
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2007