Provider First Line Business Practice Location Address:
1103 W. IRONWOOD DRIVE
Provider Second Line Business Practice Location Address:
SUITE A
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:
83814-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-667-9400
Provider Business Practice Location Address Fax Number:
208-667-9400
Provider Enumeration Date:
10/11/2005