Provider First Line Business Practice Location Address:
1641 E POLSTON AVE STE 102
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:
83854-2668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-755-2804
Provider Business Practice Location Address Fax Number:
208-765-0277
Provider Enumeration Date:
05/18/2006