Provider First Line Business Practice Location Address:
610 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTLATCH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83855-0359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-351-8968
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2019