Provider First Line Business Practice Location Address:
925 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:
83854-9049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-773-9113
Provider Business Practice Location Address Fax Number:
208-773-4911
Provider Enumeration Date:
02/26/2007