Provider First Line Business Practice Location Address:
1104 N 4TH ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-3217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-292-4873
Provider Business Practice Location Address Fax Number:
208-292-4875
Provider Enumeration Date:
02/21/2014