Provider First Line Business Practice Location Address:
302 N 5TH ST
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:
83814-2814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-664-3020
Provider Business Practice Location Address Fax Number:
208-664-3639
Provider Enumeration Date:
01/08/2007