Provider First Line Business Practice Location Address:
750 N SYRINGA ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-5275
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-9877
Provider Business Practice Location Address Fax Number:
208-777-9833
Provider Enumeration Date:
07/20/2006