Provider First Line Business Practice Location Address:
1125 E POLSTON AVE UNIT A
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:
208-640-4502
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2025