Provider First Line Business Practice Location Address:
2485 W TIMBERLAKE LOOP
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:
83815-9756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-625-5100
Provider Business Practice Location Address Fax Number:
208-625-5101
Provider Enumeration Date:
05/18/2026