Provider First Line Business Practice Location Address:
6509 HIGHWAY 2
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
PRIEST RIVER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83856-6609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-2321
Provider Business Practice Location Address Fax Number:
208-448-1317
Provider Enumeration Date:
07/22/2011