Provider First Line Business Practice Location Address:
1110 E POLSTON AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-6409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-773-1311
Provider Business Practice Location Address Fax Number:
208-773-1644
Provider Enumeration Date:
04/18/2008