Provider First Line Business Practice Location Address:
1280 E POLSTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-6056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-773-5505
Provider Business Practice Location Address Fax Number:
208-457-1712
Provider Enumeration Date:
10/13/2010