Provider First Line Business Practice Location Address:
6201 W ALLIANCE ST
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:
83858-0139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-579-4342
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2025