Provider First Line Business Practice Location Address:
101 N 4TH AVE STE 103
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:
83864-1360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-610-7134
Provider Business Practice Location Address Fax Number:
208-627-4184
Provider Enumeration Date:
10/06/2025