Provider First Line Business Practice Location Address:
1160 E POLSTON AVE STE B
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:
83854-6045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-262-0156
Provider Business Practice Location Address Fax Number:
208-262-0160
Provider Enumeration Date:
10/01/2010