Provider First Line Business Practice Location Address:
1327 SUPERIOR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-1435
Provider Business Practice Location Address Fax Number:
208-263-7812
Provider Enumeration Date:
06/30/2005