Provider First Line Business Practice Location Address:
13997 W HWY 53
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-687-0688
Provider Business Practice Location Address Fax Number:
208-687-0447
Provider Enumeration Date:
12/15/2006