Provider First Line Business Practice Location Address:
1425 S HIGH RANCH RD
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:
83814-1417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-521-2134
Provider Business Practice Location Address Fax Number:
855-930-3661
Provider Enumeration Date:
05/02/2012