Provider First Line Business Practice Location Address:
16760 N HIGHWAY 41
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:
83858-8715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-620-5190
Provider Business Practice Location Address Fax Number:
208-601-6145
Provider Enumeration Date:
05/15/2007