Provider First Line Business Practice Location Address:
1590 E POLSTON AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-5218
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-4242
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/24/2006