Provider First Line Business Practice Location Address:
2201 N GOVERNMENT WAY
Provider Second Line Business Practice Location Address:
SUITE B
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:
83814-3658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-3118
Provider Business Practice Location Address Fax Number:
208-765-7685
Provider Enumeration Date:
02/14/2007