Provider First Line Business Practice Location Address:
204 E 1ST AVE APT 4
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-217-5529
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/18/2016