Provider First Line Business Practice Location Address:
314 E ALBENI HWY
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
PRIEST RIVER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83856-9207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-4726
Provider Business Practice Location Address Fax Number:
208-448-4726
Provider Enumeration Date:
04/26/2006