Provider First Line Business Practice Location Address:
501 IDAHO RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALOUSE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99161-8704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-852-6969
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2021