Provider First Line Business Practice Location Address:
30 MCGHEE RD STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOOTENAI
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83840-0030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-0450
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/12/2024