Provider First Line Business Practice Location Address:
2022 N GOVERNMENT WAY
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:
83814-3541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-5536
Provider Business Practice Location Address Fax Number:
208-765-1194
Provider Enumeration Date:
06/27/2006