Provider First Line Business Practice Location Address:
212 S 11TH ST
Provider Second Line Business Practice Location Address:
SUITE 5
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:
83814-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-755-6121
Provider Business Practice Location Address Fax Number:
208-667-2681
Provider Enumeration Date:
03/10/2007