Provider First Line Business Practice Location Address:
12849 N FARLEY WAY
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:
83858-0940
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-505-8155
Provider Business Practice Location Address Fax Number:
208-416-6663
Provider Enumeration Date:
04/29/2024