Provider First Line Business Practice Location Address:
502 N 2ND AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-1558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-3111
Provider Business Practice Location Address Fax Number:
208-265-0427
Provider Enumeration Date:
12/11/2006