Provider First Line Business Practice Location Address:
1459 W YAQUINA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-5190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-661-6366
Provider Business Practice Location Address Fax Number:
208-773-5653
Provider Enumeration Date:
12/10/2006