Provider First Line Business Practice Location Address:
129 E POPLAR 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:
83814-3435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-819-6122
Provider Business Practice Location Address Fax Number:
866-605-2375
Provider Enumeration Date:
05/04/2026