Provider First Line Business Practice Location Address:
16768 N HIGHWAY 41
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:
83858-8715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-687-9195
Provider Business Practice Location Address Fax Number:
208-687-9750
Provider Enumeration Date:
06/01/2020