Provider First Line Business Practice Location Address:
3904 E MULLAN AVE STE C
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:
83854-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-789-9180
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2018