Provider First Line Business Practice Location Address:
402 W CANFIELD AVE
Provider Second Line Business Practice Location Address:
SUITE 3
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:
83815-7784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-762-9000
Provider Business Practice Location Address Fax Number:
208-762-9009
Provider Enumeration Date:
03/29/2007