Provider First Line Business Practice Location Address:
223 LARCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRIEST RIVER
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-261-1118
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2023