Provider First Line Business Practice Location Address:
6299 W ALLIANCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATHDRUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83858-0139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-518-8111
Provider Business Practice Location Address Fax Number:
208-599-9787
Provider Enumeration Date:
08/01/2024