Provider First Line Business Practice Location Address:
1013 E COEUR DALENE AVE
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:
83814-4121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-755-8511
Provider Business Practice Location Address Fax Number:
999-999-9999
Provider Enumeration Date:
11/15/2006