Provider First Line Business Practice Location Address:
2109 N MAIN 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-676-0104
Provider Business Practice Location Address Fax Number:
208-765-1893
Provider Enumeration Date:
08/12/2005