Provider First Line Business Practice Location Address:
2100 NORTHWEST BLVD STE 120
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:
83814-5047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-765-4343
Provider Business Practice Location Address Fax Number:
208-667-0494
Provider Enumeration Date:
10/08/2025