Provider First Line Business Practice Location Address:
1905 PINE 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:
83864-8311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-7998
Provider Business Practice Location Address Fax Number:
208-255-2423
Provider Enumeration Date:
02/03/2010