Provider First Line Business Practice Location Address:
606 N THIRD AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1594
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-8505
Provider Business Practice Location Address Fax Number:
208-263-2908
Provider Enumeration Date:
09/29/2005