Provider First Line Business Practice Location Address:
1875 N LAKEWOOD DR FL 3
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:
83814-4928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-343-0250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2025