Provider First Line Business Practice Location Address:
805 E POLSTON AVE
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:
83854-6044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-7732
Provider Business Practice Location Address Fax Number:
208-777-0201
Provider Enumeration Date:
09/19/2016