Provider First Line Business Practice Location Address:
504 E 23RD AVE
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:
83854-9104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-699-4963
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2026