Provider First Line Business Practice Location Address:
1327 W SUPERIOR ST STE 103
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:
83864-2742
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-946-5888
Provider Business Practice Location Address Fax Number:
208-920-6004
Provider Enumeration Date:
05/15/2006