Provider First Line Business Practice Location Address:
1110 E POLSTON AVE STE 1
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:
83854-6139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-773-1311
Provider Business Practice Location Address Fax Number:
208-773-1644
Provider Enumeration Date:
09/13/2006