Provider First Line Business Practice Location Address:
3803 INDUSTRIAL AVE S
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:
83815-8916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-5105
Provider Business Practice Location Address Fax Number:
208-765-3817
Provider Enumeration Date:
03/19/2007