Provider First Line Business Practice Location Address:
6456 W KAMLOOPS DR
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:
83858-6417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-5800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2013