Provider First Line Business Practice Location Address:
2005 W PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANDPOINT
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83864-9324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-263-8535
Provider Business Practice Location Address Fax Number:
208-265-2365
Provider Enumeration Date:
10/03/2006