Provider First Line Business Practice Location Address:
101 N FOURTH AVE 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:
83864-1360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-920-5600
Provider Business Practice Location Address Fax Number:
208-298-3837
Provider Enumeration Date:
06/25/2019