Provider First Line Business Practice Location Address:
2525 E SELTICE WAY
Provider Second Line Business Practice Location Address:
SUITE C
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-7463
Provider Business Practice Location Address Fax Number:
208-777-9659
Provider Enumeration Date:
02/20/2019