Provider First Line Business Practice Location Address:
5486 HIGHWAY 2 STE102
Provider Second Line Business Practice Location Address:
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-448-1216
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2014