Provider First Line Business Practice Location Address:
10200 N HAPPY TRL
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:
83858-9482
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
298-277-6302
Provider Business Practice Location Address Fax Number:
208-712-6823
Provider Enumeration Date:
08/15/2026