Provider First Line Business Practice Location Address:
1327 SUPERIOR ST
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-501-8895
Provider Business Practice Location Address Fax Number:
208-965-8128
Provider Enumeration Date:
10/07/2014