Provider First Line Business Practice Location Address:
5461 W ANTLER RD
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:
83858-7196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-755-6314
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/22/2008