Provider First Line Business Practice Location Address:
1211 MICHIGAN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-5185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-265-0432
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/05/2007