Provider First Line Business Practice Location Address:
13867 W HIGHWAY 53 UNIT 605
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:
83858-4025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-999-1054
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2026