Provider First Line Business Practice Location Address:
13621 APOLLO ST
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:
83858-5030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-868-4757
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2026