Provider First Line Business Practice Location Address:
5453 HWY 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRIEST RIVER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83856-8385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-1633
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2020