Provider First Line Business Practice Location Address:
14596 N HIGHWAY 41
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATHDRUM
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83858-8682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-687-4455
Provider Business Practice Location Address Fax Number:
208-687-4456
Provider Enumeration Date:
10/02/2025