Provider First Line Business Practice Location Address:
509 W HANLEY AVENUE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COEURDALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-8994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-5447
Provider Business Practice Location Address Fax Number:
208-666-8918
Provider Enumeration Date:
08/15/2006