Provider First Line Business Practice Location Address:
1020 MICHIGAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1788
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-255-9099
Provider Business Practice Location Address Fax Number:
208-263-6963
Provider Enumeration Date:
07/30/2009