Provider First Line Business Practice Location Address:
123 S THIRD AVE STE 1
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:
83864-1358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-691-4687
Provider Business Practice Location Address Fax Number:
208-620-2306
Provider Enumeration Date:
04/20/2026