Provider First Line Business Practice Location Address:
102 W 11TH AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-9255
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-773-1868
Provider Business Practice Location Address Fax Number:
208-773-6956
Provider Enumeration Date:
08/23/2006