Provider First Line Business Practice Location Address:
305 W KATHLEEN AVE
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:
83815-8338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-2268
Provider Business Practice Location Address Fax Number:
208-765-3540
Provider Enumeration Date:
12/18/2006