Provider First Line Business Practice Location Address:
510 ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTLATCH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-669-3186
Provider Business Practice Location Address Fax Number:
208-747-0782
Provider Enumeration Date:
05/27/2019