Provider First Line Business Practice Location Address:
1500 HWY 2
Provider Second Line Business Practice Location Address:
SUITE 336
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-2456
Provider Business Practice Location Address Fax Number:
208-265-8909
Provider Enumeration Date:
01/22/2007