Provider First Line Business Practice Location Address:
518 S 13TH ST
Provider Second Line Business Practice Location Address:
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:
83814-3919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-953-1000
Provider Business Practice Location Address Fax Number:
509-458-6087
Provider Enumeration Date:
01/23/2015