Provider First Line Business Practice Location Address:
810 N HENRY ST STE 420A
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:
83854-7665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-530-6420
Provider Business Practice Location Address Fax Number:
208-643-3321
Provider Enumeration Date:
12/09/2025