Provider First Line Business Practice Location Address:
280 MELROSE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83313-5152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-721-0151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/30/2019